**21. CEA vs. CAS in the real world**

#### **21.1. The limitations of published trials comparing CEA and CAS**

The influence of the industry is strong, where all the industry-sponsored registries had lower rates of complications compared to randomized trials. The levels of expertise of operators vary significantly among trials as well as the obligatory use of protection devices. The percentage of symptomatic and asymptomatic patients also varies rendering interpretation of results and generalizing them to the general practice an intriguing issue. There also seems a publication bias in reporting the trial results. Vascular surgery periodicals tend to note better results with CEA while cardiology journals tend to report superiority or non-inferiority of CAS.

that some patients will be best managed medically, some with medical therapy plus stenting, and some with medical therapy plus endarterectomy. These treatments are complementary and not competing. Varying treatment algorithms including more or less liberal use of each modality can be designed, patients randomly assigned to one of the algorithms, and their

1 Department of Cardiovascular Medicine, Faculty of Medicine, Cairo University, Egypt

[1] Robertson, J.T., Carotid Endarterectomy: A Saga of Clinical Science, Personalities, and Evolving Technology: The Willis Lecture. Stroke, 1998. 29(11): p. 2435-2441.

[2] Blaisdell, W.F., et al., Joint study of extracranial arterial occlusion. IV. A review of

[3] Remarks, W.C., carotid endarterectomy, in Cerebrovascular Diseases, Plum F and P.

[4] Barnett, H.J.M., M. Eliasziw, and H.E. Meldrum, Prevention of ischaemic stroke.

[5] Tu, J.V., et al., The Fall and Rise of Carotid Endarterectomy in the United States and

[6] Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. North American Symptomatic Carotid Endarterectomy Trial Collab‐

[7] Theron, J., My history of carotid angioplasty and stenting. J Invasive Cardiol, 2008.

[8] Phatouros, C.C., et al., Carotid Artery Stent Placement for Atherosclerotic Disease: Rationale, Technique, and Current Status1. Radiology, 2000. 217(1): p. 26-41.

Canada. New England Journal of Medicine, 1998. 339(20): p. 1441-1447.

2 Department of Neurology, Faculty of Medicine, Cairo University, Egypt

surgical considerations. JAMA, 1969. 209(12): p. 1889-95.

W., Editors. 1985, Raven Press Publishers: New York, NY.

orators. N Engl J Med, 1991. 325(7): p. 445-53.

and Mohammad Wasay3

Update on Carotid Revascularization: Evidence from Large Clinical Trials

http://dx.doi.org/10.5772/57153

121

results compared.[48]

**Author details**

**References**

Hussien Heshmat Kassem1\*, Foad Abd-Allah2

BMJ, 1999. 318: p. 1539-43.

20(4): p. E102-8.

\*Address all correspondence to: hheshmat@kasralainy.edu.eg

3 Department of Neurology, Aga Khan University, Pakistan
